Petition For Adjudication-Statement Of Proposed Distribution (Power Of Attorney) {OC-05}

PRINCIPAL'S ESTATE (Under Power of Attorney) COURT OF COMMON PLEAS OF ORPHANS' COURT DIVISION ESTATE OF ACCOUNT OF No. , PRINCIPAL , AGENT(S) * PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 2.4 This form shall be used in all cases involving the Audit or Confirmation of the Account of one or more Agents acting under a Power of Attorney. If space is insufficient, riders may be attached. Attach the papers required under items 3, 4 and 9, as applicable, and any instrument pertinent to the adjudication. INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: Supreme Court I.D. No.: Name of Law Firm: Address: ______________________________________________________________________ Telephone: Fax: Email: ________________________________________________________________________ * The term "Agent" shall include any person designated as an "attorney-in-fact" or acting in a similar capacity by the Principal's delegation. Form OC-05 eff. 09.01.16 Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Estate of 1. Name(s) and address(es) of Petitioner(s): Petitioner: Name: Address: , Principal Petitioner: Name(s) and address(es) of Agent(s) (if not Petitioner(s)): Agent: Name: Address: Agent: Identify any Agents who have not joined in the Petition for Adjudication/Statement of Proposed Distribution and/or the Account and state reason: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. Name and address of Principal (and, if applicable, of any Guardian appointed for Principal, of each personal representative for any Principal or Agent who has died, and of his or her counsel, identifying the capacity of each): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Judicial District or County where Principal resides, or if Principal is deceased, where Letters were issued: _______________________________________________ 3. A. Date of Principal's Power of Attorney under which Agent(s) acted: B. Date Agent(s) first exercised control of Principal's assets under Power of Attorney: (Attach copy of each different Power of Attorney granted to Agent(s) by Principal and copy of any Decree involving Agent(s) for Principal). Form OC-05 eff. 09.01.16 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 8 Estate of 4. , Principal A. Explain the reason for filing this Account (if Principal or Agent has died, state date of death, and attach a Short Certificate; if Principal has been adjudicated incapacitated, state date of Decree, and attach a copy): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ B. Is this the first accounting for this Principal's estate?. . . . . . . . . . . . . Yes If not, identify prior accountings, the accounting periods covered, and the dates of adjudication of the prior accountings. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No 5. Describe all gifts/transfers for less than full and adequate consideration made under the Power of Attorney. Identify each recipient's name, address, and relationship to Principal and/or Agent, amount of each gift/transfer, nature of each (cash or kind), and date made, with any additional explanation deemed appropriate (if none, so state): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 6. Identify every asset or interest (include title or registration and value) of Principal known to Petitioner(s) and not identified in Account, whether or not in possession or control of Petitioner(s) (if none known, so state): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Form OC-05 eff. 09.01.16 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 8 Estate of 7. , Principal Identify each existing safe deposit box of or for Principal and each one closed by Agent(s) (if not applicable, so state): Institution & Address Box No. Title or Registration Date Closed (if applicable) Are the entire contents of each safe deposit box identified in item 7 above included in the filed Account? . . . . . . . . . . . . . . . . . . . . . . . . . . . . If not, explain: Yes No ___________